History and exam

Key diagnostic factors

common

presence of risk factors

Risk factors include age over 50 years, female sex, and northern European ancestry.[9][10]

headache

There is no typical headache, but the presence of a new headache in someone with tenderness of the scalp or other associated features described below is a key symptom.[1]

scalp pain or tenderness

Diffuse or localised. The patient may notice it when brushing their hair.

aching and stiffness

Aching and stiffness in the neck, shoulders, hips, and proximal extremities that worsens after a period of inactivity and with movement. These may also be symptoms of polymyalgia rheumatica.[56]

extremity (limb) claudication

Pain may occur with repeated use of the upper extremities typically on lifting the arms above shoulder level. Rarely, pain in the lower extremities may occur in patients with large-vessel involvement.[8]

uncommon

loss of vision

The provision of fast-track pathways has mitigated the risk of visual loss, but 12% to 15% of patients still develop permanent sight loss.[43] Other symptoms may include transient loss of vision, diplopia, or changes to colour vision.[36] Rising age and the absence of headache may be risk factors for loss of vision.[43]

jaw and tongue claudication

Patients may have pain in the jaw when chewing that is unilateral or bilateral. It will typically get better with rest.[41] Likewise, the tongue may become painful on talking or chewing. It may become more sensitive in the event of impending necrosis.

arterial tenderness, thickening, or nodularity

Tenderness, thickening, and nodularity of the frontal or parietal branches of the superficial temporal arteries may be present. The facial and the occipital arteries may be similarly involved.

absent pulse

May be detected on examination of the arterial tree - at the superficial temporal, facial, radial arteries.

abnormal fundoscopy

Fundoscopic examination in a patient with ischaemia of the optic nerve may reveal pallor and oedema of the optic disc. Disc alterations follow the development of vision loss. Occasionally, cotton-wool spots and small haemorrhages are evident.

Other diagnostic factors

common

systemic symptoms

Symptoms may include low-grade fever, malaise, fatigue, and weight loss.[21][36]

uncommon

neurological symptoms

GCA mainly causes posterior circulation events due to involvement of the vertebrobasilar territory. The nature of involvement includes weakness, dysphasia, dysarthria, balance difficulties, and, rarely, hemiparesis.

bruit on auscultation

Bruits may be heard on auscultation of the carotid, supraclavicular, axillary, or brachial areas in patients with extracranial involvement.

asymmetric blood pressure

Blood pressure asymmetry may be present.

shoulder tenderness

May be related to involvement of the shoulder vasculature or co-existing polymyalgia rheumatica.[6]

limited active range of movement of shoulders and hips

In those with co-existent polymyalgia rheumatica, active range of motion of the shoulders and hips is limited due to pain, but generally the degree of tenderness is less than what might be expected in view of the severe pain.

dental pain, tongue pain, or infarction of the tongue

Oral symptoms and signs may be present.

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